Case 1: Lymphoma of the cervix
Lymphoma of the cervix is uncommon.3 It accounts for 0.008% of all primary cervical tumours and 2% of extra-nodal lymphoma in the western world.3 Presenting symptoms include vaginal bleeding,
vaginal discharge or perineal discomfort and the treatment choice is chemotherapy.
MRI characteristics of cervical lymphoma are non-specific and tend to resemble those of cervical carcinoma.
Cervical lymphoma is typically hypointense on T1 weighted sequences and relatively hyperintense on T2 weighted sequences and usually produces relatively homogenous signal intensity and diffuse enlargement of the cervix,
as in Case 1 (Figure 4).4,5 As a general rule,
preservation of the cervical epithelium with diffuse enlargement of the cervical stroma suggests the diagnosis of cervical lymphoma.4,5
Case 2: Ewings Sarcoma of the cervix
Ewings sarcoma belongs to the Ewing’s family of tumours that arise from mesenchymal progenitor cells.6 Ewings sarcoma typically occurs at osseous sites with primary cervical involvement an extremely rare occurrence.6 Incidence increases with age. Only 19 case reports can be found in the literature and the most common presenting complaint is vaginal bleeding.6 There is no consensus regarding treatment given the rarity of this condition.
In Case 2 (Figure 5),
the patient was middle-aged and the MRI demonstrated extensive local cervical disease with significant pelvic adenopathy,
extensive peritoneal nodes,
omental cake and ascites.
Case 3: Small cell carcinoma of the cervix
Small cell carcinoma is a type of neuroendocrine tumour,
along with carcinoid,
atypical carcinoid and large cell neuroendocrine carcinoma.7 Neuroendocrine tumours of the cervix are rare and highly aggressive. Imaging alone cannot reliably differentiate neuroendocrine tumours from other types of cervical cancer.
Neuroendocrine tumours typically present as a large lobulated mass demonstrating homogeneous high signal on T2-weighted sequences and intense enhancement on dynamic multiphase T1-weighted sequences.7 As demonstrated in Case 3 (Figure 6),
small cell carcinoma of the cervix frequently demonstrates significant lymphadenopathy and parametrial invasion.8
Case 4: Leiomyosarcoma of the cervix
Cervical sarcomas are uncommon tumours arising from uterine cervix constituting less than 1% of all cervical malignancies.9 They are aggressive neoplasms that tend to present in younger patients at an advanced stage with a poor overall prognosis.9 Leiomyosarcoma of the uterine cervix is extremely rare.
No specific imaging features are described and confirmation is based on pathological and immunochemical staining. In Case 4 (Figure 7),
the patient presented with a very bulky mass arising from the ectocervix which distends the upper vagina but does not invade through the vaginal wall.9
Case 5: Myeloid Sarcoma of the cervix
Myeloid sarcoma is a solid tumour composed of immature myeloid cells at an extramedullary site.9 It most commonly occurs in bone,
soft tissue,
periosteum,
lymph nodes and skin.
Involvement of the female genital tract is extremely rare with only 23 cases of myeloid sarcoma of the cervix reported.9 It typically presents with vaginal or post-coital bleeding.9 No characteristic imaging features have been identified in the literature.
The primary diagnosis is based on pathological and immunohistochemical analysis. In case 5,
(Figure 8),
the patient presented with an isolated pelvic mass involving the cervix which demonstrated relatively homogenous slightly hyperintense signal intensity on T2-weighted sequences.9
Case 6: Primary rectal tumour invading cervix and vagina
Rectal carcinoma may occasionally invade local structures.
It is estimated that 10% of all rectal tumours demonstrate locally advanced disease with direct invasion of adjacent organs at the time of diagnosis (Stage T4b).10 The most frequent sites of local invasion are the bladder and small bowel.11 Locally advanced rectal cancer directly invading the vagina and cervix is rare.11 In case 6 (Figure 9),
the patient presented with a polypoid mass arising from the rectum with an associated peritumoral fistula involving the vagina and cervix.
Case 7: Cervical metastases
Cervical metastases are extremely rare.
Occasional case reports in the literature have noted cervical metastases with colorectal carcinoma,
gastric carcinoma,
breast carcinoma and ovarian cancer.12-15 In Case 7 (Figure 10), the patient had a history of colorectal carcinoma 3 years previously.
Abnormal mass lesions demonstrated within
the cervix,
endometrium and right adnexal region were proven to represent metastases from colorectal carcinoma.
Case 8: Pelvic side recurrence
Tumour recurrence is the development of new local tumor or metastasis at least 6 months after treatment.16 Risk factors for recurrence include tumour stage,
tumour size,
depth of stromal invasion,
histological type and node status at initial presentation.17 Recurrence usually occurs at the vaginal vault,
cervix,
parametrium,
pelvic side wall,
bladder and rectum within 2 years following completion of initial treatment.
Recurrence can also present in lymph nodes or within local or distant organs as metastasis.17 In case 8,
the patient presented with a large pelvic sidewall mass (Figure 11).
She had undergone surgery for cervical carcinoma 12 years previously.
There was parametrium extension at the time of initial presentation and no adjuvant treatment was administered. MRI has high sensitivity but low specificity for recurrent disease and there is a diagnostic challenge differentiating recurrence from radiation necrosis.
Kaur et al18 argue that dynamic contrast-enhanced imaging increases the accuracy of identifying recurrence by noting early,
enhancing intermediate/high T2 signal mass lesions.